The Irreparable Rotator Cuff Tear:Trauma 101 Rotator Cuff Session

Brian Grawe, MDAssistant ProfessorOrthopaedics & Sports Medicine5/11/2017

Brian Grawe, MD

Assistant Professor

Phone Number: 513-558-4516

Email: grawebn@ucmail.uc.edu

I HAVE NO DISCLOSURES or COI

Outline• Background

• Definition & Classification

• Pathomechanics

• Clinical Presentation

• Treatment Options

• Summary

“20 second TO”: What this talk is NOT

• Comprehensive review of literature for treatment options for the irreparable rotator cuff tear

• Endorsement of any one treatment strategy

• Comprehensive review of rotator cuff tear arthropathy

Background: Rotator Cuff DiseaseEpidemiology

Millions of Americans have some aspect of rotator cuff disease

Full-thickness tear• 28% (> 60 yo)• 65% (>70 yo)

Those with asx tear• 50% chance of developing sxs w/in three years• 40% chance of tear progression

BackgroundIrreparable Rotator Cuff Tear (IRCT)• Complex clinical spectrum

Lack of consensus (regarding treatment)

• Progression Fatty infiltration Tendon retraction Inelastic tissue Scar & adhesion formation

• Repair Unpredictable Highly morbid

Definition & Classification

• Massive tear ≠ Irreparable tear Lack of healing potential Not technical feasibility

• Size (USA) Cofield JBJS 1985 > 5 cm

• # of Tendons (Europe)Gerber JBJS 2000 Prognosis, function, outcome

Consider: amount of humeral head exposed, tear pattern, tissue mobility

PathomechanicsSuspension Bridge

Force Couple Concavity-Compression Cuff centers the head

JBJS 1999 & 2007

Impoverished biologic environment Attritional changes to tendon Attritional changes to muscle Relative hypovascularity

Clinical Presentation (IRCT Pearls)

History• Determine “CC”

– Pain ?– Weakness ?

• Was there an acute event?– Tear extension– Effect early tx

Physical Exam• Pseudoparalysis

– Pain ?– Fulcrum loss?

• CA arch violation– Escape

• Fossae atrophy• Lag signs

JBJS Br 1998

Clinical Presentation (IRCT Pearls)

Radiographs• AHI

– < 5mm CORR 1990

– Fatty infiltrationJSES 2008

MRI• Size• Retraction• Fatty infiltration

– Stage 3 & 4 no improvement after repair (AJR 2005)

***U/S cannot determine reparability***

Treatment Options

Nonoperative

vs

Operative

….Who, What, Where, How, Why, and When ?

TAYLOR THE PLAN: patients goals, symptoms, demands (patient and shoulder)… remember the snowflake

TreatmentNonoperative• Physical therapy Subscap; trapezieus; ANTERIOR DELT Scapular stabilization

• Corticosteroid injection PT participation Defines true

pseudoparalysis v pain

• Treat people not x-rays

JBJS 2008 & 2012

Treatment Operative• Arthroscopic

• Reconstruction Superior CapsuleGrafts Tendon Transfers

• Arthroplasty Hemi RSA

Treatment: Arthroscopic• Rotator cuff debridement

Burkhart CORR 1991; Gartsman JBJS 1997

• Partial Repair (margin convergence) (HH coverage) Burkhart Arthropscopy 1994; Duralde JSES 2005

• Reverse decompression (tuberoplasty) (maintains arch) Fenlin JSES 2002

• Biceps tenotomy Walch JSES 2005; Boileau JBJS 2007

• Suprascapular nerve release Lafosse Arthroscopy 2007

• Eliminate all pain generators !!! Steroid restores elevation or not ready for arthroplasty Bad OA or significant cuff atrophy

Treatment: Reconstruction (Salvage?)Superior capsule (NKOTB)• Biomechanical sound

Mihata AJSM 2016• Clinical results promising

Mihata Arthroscopy 2013

Tendon Transfer • (<50, weakness, ready for rehab)• Lat Dorsi

Gerber CORR 1992• Pec Major

Elhassan JBJS 2008

… Scaffolds (bridge) beyond scope … Data is conflicting & conflicted

Treatment: ArthroplastyHemiarthroplasty• Balance mechanics - AKA -• Preserved coronal plane force couple (intact subscap)• Conventional

67% or 63% good results; previous SAD bad Sanchez Sotelo JBJS 2001 Field JBJS 1997

• EAS head Copeland J Surg Orthop Adv 2009

• Function and cost better with RSA Leung JSES 2012; Leung JSES 2012

Treatment: Arthroplasty

Reverse Shoulder Replacement (RSA)• TSA leads to loosening via rocking horse

Franklin & Matsen Arthroplasty 1988

• COR moved medially (not too much) and distally• Improve fulcrum of deltoid

(lengths momement arm and tensions)• Prosthesis more constrained; more stable• Higher complication rate

Treatment: ArthroplastyReverse Shoulder Replacement (Results)• Grammont’s modification (invented for CTA)• Clinical Success

Boileau JSES 2007 Wall JBJS 2007 Frankle JBJS 2010

• DO’s Elderly; low demand; arthropathy;

consider lat tranfer too

• DON’T’s Young age; high function preop;

neurologic dysfunction

• Maybe’s Revision surgery; no pseudoparalysis;

severe concomitant cervical radiculopathy

Case 1: LE

47 yo male s/p MVC

Poly trauma: flail chest, bilateral shoulder injuries w/ acromial fracture ORIF

Underwent attempt at RCR – failed

Now 8 months from initial injury

Case 1: LE

SummaryChronic subscap, supra, and infra tearFailed previous repair attemptSignificant atrophy of supra

PlanPectoralis major transferSCR

Case 1: LE

* Pec transfer: under coracoid

* ASES:**39.9 → 100**

*Back to work

Case 2: CJ

• 52 yo female with long standing history of shoulder pain and weakness

• Unable to perform ADLs

• Failed PT and numerous steroid injections

Case 2: CJSummaryRotator cuff arthropathyRelatively young patientProfound external rotation lag

PlanHemi-arthroplastyEAS headTendon transfer

Case 2: CJ

Summary• Treat all patients like snowflakes

• Define expectations early

• Consider injection to define pseudoparalysis

• PT should focus on ANTERIOR DELTOID

• Arthroscopic surgery can help in certain pts

• RSA should not be take lightly Good pain control Overhead power less reliable Complication rate relative high

END

Thank you!Questions / Comments